7Operative approaches to the Neck.pptxxx

Neck

1. Operative approaches to the Neck

2. Structures at Risk Musculoskeletal Vertebral bodies Cervical muscles and tendons Clavicles, 1 st and 2 nd ribs Hyoid bone Glandular Thyroid Parathyroid Submandibular Parotid glands

3. Anatomical Review

4. Structures at Risk Visceral structures Thoracic duct Esophagus Pharynx Larynx Trachea

5. Structures at Risk

6. Structures at Risk

7. Zones of the Neck Zone III - Clavicles and sternal notch to cricoid cartilage Zone II – Cricoid cartilage to the angle of mandible Zone I – Angle of mandible to base of skull III II I

8. Zones of the Neck Zone I Zone II Zone III

9. Zone I Subclavian vessels Brachiocephalic veins Common carotid arteries Aortic arch Jugular veins Esophagus Lung apices C- spine/cord Cranial nerve roots

10. Zone II Carotid and vertebral arteries Jugular veins Pharynx Larynx Trachea Esophagus C-spine/cord

11. Zone III Salivary and parotid glands Esophagus Trachea Vertebral bodies Carotid arteries Jugular veins Cranial Nerves IX-XII

12. Subtotal thyroidectomy

13. A suitable incision for parotid surgery.

14. Tracheostomy .

15. OPERATIONS ON NECK Tracheotomy and tracheostomy The tracheotomy is opening the trachea with entering a special tube into its lumen to let the external air into the respiratory tracts avoiding hampers at asphyxia of various origins. The tracheostomy is an opening of the lumen of the trachea with sewing the edges of the cut trachea to the edges of the skin; as a result, there appears a tracheostoma - an open aperture that allows the patient breathing freely at obstruction of the upper lying parts of the trachea and larynx.

16. According to the level of dissection there are superior, middle and inferior tracheotomies. The key point in this case is the isthmus of the thyroid gland: dissection of the first tracheal rings upward of the isthmus is the superior tracheotomy; behind the isthmus (cutting it as a rule) - the middle one, and below the isthmus - the inferior tracheotomy. As it is impossible to apply inhalation narcosis (due to obvious reasons), they use a local anaesthesia at tracheotomy and sometimes an intravenous one while at deep asphyxia the surgery is carried on with no anaesthesia to waste no time.

17. The position of a patient during the whole operation is on their back with a roll under shoulder-blades. As surface landmarks, they usually choose the superior and inferior edges of the thyroid cartilage, the cricoid cartilage, the isthmus of the thyroid gland, and tracheal rings below the isthmus of the thyroid gland.

18. Superior tracheotomy A transverse 5 cm long cut of the skin is made at the level of the cricoid cartilage. Together with the skin, the subcutaneous adipose tissue and the superficial fascia with the  platysma   are dissected. The edges of the wound are pulled apart by the Farabeufs plate surgical retractors to open the linea alba of the neck. It is always cut longitudinally, mostly by the grooved probe. The edges of the linea alba along with the adjusting fascial capsules of the sternothyroid and sternohyoid muscles are pulled aside by the blunt retractors. In the pretracheal space, the isthmus of the thyroid gland is picked off and made free of ligaments.

19. The isthmus is drawn downward by a blunt retractor. At the flanks of the median line, sharp one-toothed retractors are pricked into the 1 st  or 2 nd  tracheal ring; the larynx and trachea are fixed by the retractors at the opening of the trachea and entering the tracheotomy cannula (fig. 5.28). Opening of the trachea (dissecting 1 or 2 of its rings beginning from the second) is performed from the bottom upwards by a sharp scalpel held so that the tip of the index finger on its back stay no more than 1 cm from the apex of the cutting part. It is done to prevent the scalpel from falling into the tracheal lumen and injuring its posterior wall. The edges of the dissected cartilage are cut off so that there appears an oval opening on the anterior surface.

20. tracheotomy tube (cannula) is entered into the trachea. The tube is entered in three stages as if screwing it into the tracheal lumen A trachea dilator is entered into the tracheal cavity through the cut; the one-tooth retractors are carefully taken back and a so that not to injure the posterior wall of the trachea. First, the tube is entered transver -sally according to the neck length (the faceplate is placed sagittally ) and then gradually turned downand forwards (now the faceplate takes the frontal position and with its posterior surface faces the anterior surface of the neck); finally, the tube is pushed into the tracheal lumen until the faceplate touches the skin.

21. The wound is sutured layer-by-layer beginning from the angles, in the direction to the tracheotomy tube: the edges of the fasciae and the subcutaneous cellular tissue are sutured with catgut, the edges of the skin cut - by silk with interrupted stitches. Gauze stripes are put into the eyes of the tube's faceplate and tied around the neck.

22. Fig. 5.28. The superior tracheotomy. Stages of an operation: 1 - a transverse cut of the skin, subcutaneous tissue, superficial fascia with the platysma ; 2 - the linea alba of neck is dissected precisely between the internal borders of the sternohyoid muscles; ligaments going to the superior border of the thyroid gland isthmus are cut off from the cricoid cartilage; 3 - the thyroid gland isthmus is pulled down; the trachea fixed with sharp one-tooth clamps is opened; 4 - a tracheotomy tube is begun to be entered (its faceplate in the sagittal plane); 5 - the tube at the end of its entering (its faceplate in the frontal plane)

23. The inferior tracheotomy The inferior tracheotomy is usually performed in children. It is done mostly as the superior one considering that the trachea lies deeper and is separated from the superficial layers by the thicker cellular tissue of the pretracheal space between the 3 rd  and 4 th  fasciae. The unpaired thyroid venous plexus as well as a possible  a. thyroidea ima   should be also kept in memory.

24. Operations on thyroid gland Operations on the thyroid gland are rather common. At diffusion or nodal thyrotoxic goitre , the resection of the gland is done, i.e. removal of its part; at cancer, the gland is removed completely along with the surrounding cellular tissue and lymph nodes situated under it. At these surgeries the recurrent laryngeal nerve going along the posterior surface of the gland is frequently injured and the parathyroid glands are then removed as well.

25. The operation to minimize these complications was introduced by Soviet surgeon O.V. Nikolaev . It is called the subtotal, subfascial resection of the thyroid gland. It is called subtotal because almost all of the gland's tissue is removed; and it is called subfascial as it is performed within the fascial capsule for the gland, i.e. under this capsule. As it has been said in the section about the thyroid gland topography, the parathyroid glands are situated under the fascial capsule while the recurrent laryngeal nerves lie outwards of the capsule (see fig. 5.16). Therefore, the intervention inside the fascial capsule cannot lead to injuring the recurrent laryngeal nerve, and a small safe layer of the thyroid gland on its posterior surface preserves the parathyroid glands from injuries.

26. The operation is performed with a transverse, a little arcuate approach 1-1.5 cm upward of the jugular notch between the anterior borders of the sternocleidomastoid muscles. After the skin, subcutaneous cellular tissue and the  platysma   with the superficial fascia have been dissected, the upper flap is pulled apart up to the superior edge of the thyroid cartilage.

27. The 2 nd  and 3 rd  fasciae of neck are cut longitudinally in the middle between the sternohyoid and sternothyroid muscles. To open the thyroid gland, the sternohyoid and sometimes sternothyroid muscles as well are dissected transversally. The 0.25% Novocain solution is injected under the fascial capsule of the thyroid gland; it blocks the nerve plexus and makes it easier to separate the gland from the capsule. The separated gland is resected; the bleeding is stopped by hemostatic forceps. After a careful hemostasis the edges of the capsule are sutured with the continuous catgut stitches over the stump. The sternohyoid muscles are sutured with catgut U-shaped sutures. The edges of the fasciae are treated with interrupted catgut sutures, the cutaneous edges - by the interrupted silk or synthetic sutures.

28. Operations at abscesses and phlegmons of neck Opening the submandibular phlegmon The skin cut is performed from the angle of mandible forwards parallel to its inferior edge and 2-3 cm below it. The cut is 5-6 cm long. The subcutaneous tissue and then the  platysma   with the superficial fascia are dissected. The  r. marginalis mandibu-laris n. facialis   going upward, at the angle of mandible should be treated with special care. Further, the capsule of the submandibular gland is cut (the 2 nd  fascia of neck) and pus is evacuated. If the gland itself is affected with pus, it is removed with the surrounding cellular tissue and lymph nodes (fig. 5.30).

29. Thank you For Attention!